263
PROSPECTS FOR CHANGE IN PUBLIC MENTAL INSTITUTIONS CARL I. COHEN, M.D., M.A. Assistant Professor ofPsychiatry New York University-Bellevue Medical Center
Department ofPsychiatry Office ofUrban Health Affairs This paper is based on a manuscript that was awarded first prize in a essay contest sponsored by the New York District Branch of the A.P.A.; the paper was presented to this group on April 11, 1974. SUMMARY
Because of the incompatibility of variables (viz. actors, milieu concept, institution, society) with each other as well as the potential areas of strain contained within each variable, it is improbable that state mental institutions can adapt a patiencentered (therapeutic) milieu. Evidence is presented in order to substantiate this
hypothesis. social civil court and have for state institutions to rather than care. In order to this state institutions have emptied their wards. (35) Many psychiatric units have been reorganised along the lines suggested by Maxwell Jones (25) in an attempt to create a ’therapeutic community’ or ’patient-centered care’. Talcott Parsons (39) has ascribed to all mental hospitals four tasks : (a) custody of the deviant; (b) protection of the community; (c) socialisation of the deviant; (d) therapy. He observes that it is inevitable that these goals will conflict with one another. Furthermore, these tasks must be comprehended in the light of the conflicting needs of patients, staff, and the institution. (54) This paper proposes that it will be impossible to attain a ’true’ therapeutic milieu in state institutions because of the incompatibility of the variables (actors, milieu concept, institution, society) with each other. For example, the actors’ (staff and patient) roles may clash with the needs of the hospital or with the aims of the milieu community. Furthermore, each variable contains within itself areas of strain -actors have conflicting goals; the milieu concept is vague and of dubious value. A few of the conflicting relationships are delineated on page 264. various EGISLATORS, scientists, libertarians, psychiatrists, decisions underscored the necessity mental L provide therapy merely custodial (56) edict, comply with
I. The Actors A. The Patient-Definitional Problems At many public mental institutions patients are admitted against their will. For example, one-half of Bellevue’s admissions are on an involuntary basis. This
Address correspondence to : CARL I. COHEN, M.D., M.A. N.Y. U. Medical Center, Urban Health Affair 550 First Avenue, New York, 10016 Downloaded from isp.sagepub.com at DALHOUSIE UNIV on June 25, 2015
264
a clash between the patient and the doctor (and the community). Criteria for emergency admissions usually entail the notion of danger to self or others. Kumasaka and Stokes (27) have noted how lawyers and psychiatrists markedly differ on the concept of ’dangerousness’. ’Mental illness’ also is a rather nebulous concept and this lack of clarity regarding mental illness may pose a dilemma for the staff concerning the nature of what they are treating and it may put them at odds with the patient. The medical definition promulgated by the psychiatric profession has been undermined by other disciplines. Sociologists (15, 48, 34) have suggested that mental illness is a type ofI deviancy that is not readily classified under the more common deviant categories (e.g., theft, murder, etc.). Burger and Luckman (6) have pointed to psychiatry (along with technology, philosophy, and religion) as one of the legitimators of society. Laing (29) has asserted that schizophrenia is the logical escape from an insane environment (family or society). Mowrer (36) and Szasz (58) have proposed that mental illness represents a deviation from ethical norms, and they have provided cogent arguments debunking the physical basis of mental illness. Hurvitz (24) and Halleck (19) have described the political nature of psychotherapy-because most therapists focus on the intra-psychic sphere, they often obfuscate societal factors that may be impinging upon the patient. Socioeconomic factors similarly affect our conceptualisation of mental illness. Hollingshead and Redlich (22) have demonstrated the higher incidences of schizophrenia among lower socioeconomic groups. Lee and Temerlin (30) have suggested that knowledge of a patient’s social class biases the therapist’s diagnosis and prognosis assessment, i.e. lower economic groups are given more severe diagnosis. Several investigations of psychological tests (17,60) have uncovered racial and socioeconomic biases.
implies
I
I
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265 Because of public ignorance and fear of mental illness (41, 55) psychiatrists often pressured into making false-positive errors, believing it is better to error on -he side of caution. (49, 28) Hence, psychiatrists are often caught in the conflict between the patient and the community. are
~3. l.
The Staff Aides Staff needs and personalities often clash with the expectations of the milieu therapy. Studies have suggested that attendants’ personalities may be incompatible with a therapeutic community structure. To wit, Gilbert and Levinson (14) have noted that aides divide into two categories-’humanistically-oriented’ and ’custodialnriented.’ Pine and Levinson (42) believe that these two orientations are part of the aides total ideology and personality system; Appleby et al. (1) have demonstrated that new aides (less than six months experience) differed little in ideology and in opinions concerning mental illness than more experienced aides. Cohen and Struening (9) have reported that attendants scored high on authoritarianism, while psychologists, psychiatrists, and social workers scored low; nurses were midway between the two groups. The authors noted that if authoritarianism is characterologically imbedded as Adorno has suggested, no lecture series or brief course ill alter the aides’ attitudes. Pearlin (40) has pointed to the high degree of alienation among hospital orkers. Aides were the most vulnerable to alienation due to their low salaries and decreased opportunities for occupational advancement. As Herz (20) observed, therapeutic communities, while tending to blur roles, provide no mobility between oles, i.e. social workers do not become psychiatrists. Hence, milieu therapy may not significantly reduce alienation. Scheff (59) believes that the aides’ alienations and ow status may result in their sabotaging innovative efforts and maintaining the tatus quo. Wilensky and Herz (62) have confirmed this hypothesis by demonstrating hat lower-level personnel in a therapeutic community appeared to be reluctant to hare responsibilities and tend to guard jealously their assigned functions. Nurses. Nurses are overwhelmingly female [99%] and predominantly white [83-97%]. (10) The dominance of females in nursing may create problems with male physicians, hereas their whiteness may result in conflict with aides who are chiefly Black and uerto Rican (2) [see below]. Parloff (38) has demonstrated that for many nurses their previous training (e.g. emphasis on physical care) may be incompatible with ward-milieu philosophies nd despite long stay on the units, they are unable to adjust to many of the milieu
.
oncepts. .
Physicians Psychiatrists
are largely males [88%], (4) white [99%], (59) and in the highest socioeconomic class. (24) Band and Brody (2) have alluded to the potential conflicts hat can evolve between the physician and personnel in the lower socioeconomic lasses (nurses and aides); as well as the potential friction created by racial and difference. Physicians also find themselves enmeshed between various structural and educational commitments. In one hospital study, Stanton and Schwartz (54) reported hat therapists spent only 53% of their time with patients. In another hospital,
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266 Rosenhan
(47) noted that psychiatrists emerged on the ward an average of 6.7 times for rather brief periods. The remainder of a physician’s time may be divided into teaching duties, administrative work, and staff conferences. In state hospitals, administrative duties have traditionally been quite onerous. Cumming and Cumming (11) have indicated that psychiatrists frequently run into difficulty trying to resolve therapy versus administrative duties-often the physician yields to the old ways and the hospital culture rather than accepting significant administrative responsibility. Scheff (50) has pointed out that physicians have a ’trained incapacity’ for ward leadership based upon their previous training for individual psychotherapy. In addition to administrative overload, Belnap (3) has enumerated severa reasons for high physician turnover at state institutions : (a) low prestige; (b) pool working conditions; (c) higher salary elsewhere; (d) no opportunities for research (e) impossible to practice; (f) ill-defined and poor relations with superiors an professional auxiliaries. It would seem highly unlikely that the introduction into a state institution of a therapeutic milieu will result in a marked reduction in administrative overload o eliminate the etiology of physician turnover. per
day
II.
The Structure Smith and Levinson (53) believe that while the goal of the mental hospital is to assist the patient in the cure of his illness, the structure of the hospital organisation may hinder or help the effort. There are four basic problems created by the structure :
A.
Standardisation Versus Individuation Kahne (26) has illustrated how the bureaucratic nature of the institutio directly affects patient care-objective reporting becomes the standard for makin decisions; it is found in nursing reports, mental status examinations, and cas histories. For example, only disagreeable acts are reported, successes are rarely noted There is little evidence in the literature to suggest that recordkeeping has beer significantly modified in therapeutic milieus. Wooden (64) has warned that the difference between a hospital and a busines should be kept in mind; quite often the financial needs of an institution may com before patient care. B. Communication Difficulties in communication apparently are not eliminated by the therapeuti milieu. In the archetypical custodial care facility, Belnap (3) uncovered a shar dropoff in communication between Level II personnel (nurses, social workers occupational therapists), and Level III staff (aides). Etzioni (13) and Band et al. (2 have indicated that in the therapeutic milieu aides continue to remain circumspec about reporting communications upward out of fear that it will be used agains them. C. Status and Authority. It is difficult to imagine that patient-centered therapy will eliminate the statu rankings of participants. Etzioni (13) has asserted that the ward is not isolated fro the community, and cultural values are carried onto the ward. Band and Brody (2 have argued that racial, sexual, and socioeconomic status are potential arenas o conflicts among personnel and between staff and patient. Herz et al. (21) hav reported that attempts at role-blurring resulted in competition, hostility, conflic and anxiety among staff and patients. Oviatt (37) has similarly uncovered increase staff tensions engendered by overlapping of workers’ functions. ’
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267 Another method of status differentiation that may not be completely extinguished by the implementation of a therapeutic milieu is the ’diagnostic culture’. (32) In a mental hospital, the ability to employ psychiatric jargon often becomes a status
symbol. Relationship Between and Within Occupational Groups
D.
When there is too much functional differentiation of staff, it often becomes difficult to reach a concensus (26) or it may result in spotty care. (64) For these reasons, efforts to minimise occupational differences are often encouraged in therapeutic communities. Nevertheless, Etzioni (13) has contended that staff still maintain their affiliation with their professions through associations, journals, meetings, etc. Hence, many of the inter-disciplinary frictions continue to exist. III. Efficacy ofthe Therapeutic Milieu Another factor that may ultimately affect the prognosis of transformation to therapeutic wards in state institutions is whether milieu therapy is more efficacious than the custodial model. If there are repeated failures utilising milieu treatment, staff will become frustrated and they will revert to their previous roles. The data concerning its effectiveness are quite controversial. Clark (7) has described improvement in the behaviour of chronic patients subject to milieu therapy, but he is uncertain as to whether environmental conditions can alter the underlying psychosis. Letemendia et al. (31) studied a hospital ward run on the lines suggested by Maxwell Jones and after five years of study, long-stay patients experiencing a therapeutic milieu showed no differences when compared to a control group. Rapoport (43) has questioned whether techniques learned in the hospital are equally applicable in the community. Wing and Brown (63) have reported opposite findings they noted a diminishment in underlying pathology secondary to environmental alterations. Clark (7, 8) has pointed to the significant reductions in the length of hospitalisation that milieu therapy can produce when combined with drug and psychotherapy. However, as the sole treatment modality for Schizophrenia, milieu therapy has been shown to be the least effective of all therapies (versus drug, ECT, and psychotherapy). (33) Thus, our current exhortations to create ’therapeutic’ (patient-centered) institutions relies heavily on faith and on our personal beliefs on humanitarianism and and democracy rather than on objective data.
Why Organisations Do Not Change-The (Change’ Literature Merely altering the environment to a milieu regimen is not sufficient to guarantee therapeutic success; Hooper (23) discovered that despite apparent changes IV.
in the ward structure, there was still a minimum amount of interaction between the patient and the personnel. The literature is replete with references concerning staff resistance to change. (50, 11, 3) Dykins et al. (12) have noted that a hospital culture frequently operates on a variety of premises such as ’others are not interested in change’ or that ’these things have been tried before’. Nevertheless, despite these responses by staff members, the hospital under study had historically accepted new treatment techniques. Therefore, staff resistance to change may not be such a potent element, several authors (16, 5) have posited other items that may play a more significant role in impeding innovations :
A.
Lack of clarity regarding the innovations Schwartz’s (52) observations in one hospital in which
nurses
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failed
to
adapt
to
268
therapeutic milieu have suggested that this failure lies with the administrator who has a responsibility to interpret the role to them, and to help them play the new role. One of the major difficulties with a therapeutic community is lack of clarity regarding what is expected from the staff. Part of the problem lies in the inability to arrive at a concensus regarding a definition of ’therapeutic milieu’; (65) Fritz Redl (46) has drolly commented that there are at least seven commonly used
a
definitions.
I
Rapoport (43, 45, 46) has amply demonstrated the confusion among staff regarding when to act ’permissively’ or when to be ’democratic.’ Wilensky and Herz (62) believe that the inappropriately paternalistic attitude that staff exhibited towards patients on one therapeutic ward stemmed from a poor understanding of the theoretical bases for staff-patient relationships. B. Lack of needed capabilities Hall (18) has maintained that the new milieu approach has not given sufficient attention to the education of nurses and aides. Except for a brief educational session, the aides are totally unprepared to function adequately in a treatment milieu. If one compares the education of a psychiatric resident (medical school, seminars, supervision, personal analysis) with that of an aide, one can see the ludicrousness in the aide’s situation. Furthermore, one must consider data presented by Cohen & Struening (9) alluding to the possible incompatibility of the aide’s personality structure with milieu therapy. C. Incompatibility of organisational arrangements with the innovation Schwartz and Schwartz (51) have summarised three organisational items that may impede change : (a) large ward size and low staff-patient ratios; (b) conflicting goals (custodial versus treatment); that is, despite some enhanced permissiveness there is still a necessity to maintain order; (c) forced standardisation due to overall hospital policy, government regulations, etc. Rapoport (45) has also delineated several factors external to the hospital that may conflict with ward policies. For example, a limitation on sexual freedom on the ward may result because of societal pressure. T,a ck of staff motivation Schwartz (52) has asserted that new roles must offer various rewards, and that attPntion should be directed to the gratifications being provided. She exhorts administrators to constantly search for ways to increase motivation and to decrease apathv : attempts should be made to fit the new role into the more traditional roles and value systems. Stotland and Kobler (57) believe that high staff morale is essential for the survival of a therapeutic milieu approach. They contend that if morale markedly diminishes the organisation will ultimately die.
D.
SUMMARY
Because of the incompatibility of variables (actors, milieu concept, institution, society) with each other as well as the potential areas of strain contained within each variable, it is improbable that state mental institutions can adapt a patientcentered (therapeutic milieu). Evidence is presented in order to substantiate this
hypothesis. Downloaded from isp.sagepub.com at DALHOUSIE UNIV on June 25, 2015
269 REFERENCES
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Appleby, L., Ellis, N. C., Rogers, G. W., Zummerman, W.: ’A Psychological Contribution to the Study of an Hospital Structure.’ J. of Clinical Psychology, 1961, 17:390-93. Band, R. I. and Brody, E. B.: ’Human Elements of the Therapeutic Community.’ Arch ofGen. Psychiatry, 6 : 307-41. Belnap, I.: Human Problems of a State Mental Hospital. New York : McGraw-Hill Book Company, 1956. Blain, D.: ’Woman in Psychiatry.’ In American Psychiatric Assn. (ed.) Careers in PsyChiatry. New York: The MacMillan Company, 1968, pp. 111-28. Brim, O. and Wheeler, S.: Socialisation After Childhood. New York: John Wiley and Sons, Inc., 1966. Burger, P. and Luckman, T.: The Social Construction of Reality. New York: Doubleday and Company, 1967. Clark, D. H.: ’The Therapeutic Community—Concept, Practice and Future.’ Brit. J. Psychiat., 1965, 111:947-54. Clark, D. H., Hopper, D. and Oram, E.: ’Creating a Therapeutic Community in a Psychiatric Ward.’ Human Rel., 1962, 15 :123-47. Cohen, J. and Struening, E. L.: ’Opinions about Mental Illness in the Personnel of Two Large Mental Hospital.’ J. of Abnormal and Social Psychology, 1967, 64:349-60. Cooper, V., Baller, P. and Ackerhalt, J.: ’Nursing Education: Teach the Woman to know Her Place.’ Health-PAC Bulletin, September, 1970, 7-11. Cumming, J. and Cumming, E.: ’Social Equilibrium and Social Change in the Large Mental Hospital.’ In M. Greenblatt et al. (eds.) The Patient and the Mental Hospital. Glencoe: The Free Press, 1957, pp. 49-71. Dykins, J., Hude, R., Orzack, L. and York, R.: Strategies ofMental Hospital Change. Boston: Commonwealth of Mass., 1964. Etzioni, A.: ’Interpersonal and Structural Factors in the Study of Mental Hospitals.’ Psychiatry, 1960, 23:13-22. Gilbert, D. and Levinson, D.: ’Role Performance, Ideology, and Personality in Mental Hospital Aides.’ In M. Greenblatt et al. (eds.) The Patient and the Mental Hospital. Glencoe: The Free Press, 1957, pp. 197-208. Goffman, E.: Relations in Public. New York : Harper Colophon, 1971, pp. 335-90. Gross, N., Giacquinta, J. and Bernstein, M.: Implementing Organisational Innovations.
New York: Basic Books, 1971. 17. Gynther, M.: ’White Norms and Black MMPI’s.’ Psychological Bull., 1972, 78:386-402. 18. Hall, B.: ’Vicissitudes of Psychiatric Ward Personnel.’ In M. Greenblatt et al. (eds.) The Patient and the Mental Hospital. Glencoe : The Free Press. 1957, pp. 231-36. 19. Halleck, S. L.: The Politics of Therapy. New York : Science House, 1971. 20. Herz, M. I.: ’The Therapeutic Community: A. Critique.’ Hosp. and Community Psychiatry, 1972, 23:69-72. 21. Herz, M. I., Wilensky, H. and Earle A.: ’Problems or Role Definition in the Therapeutic Community.’ Arch. of Gen. Psych., 1966, 14:270-76. 22. Hollingshead, A. and Redlich, F.: Social Class and Mentall Illness: New York: John Wiley and Sons, 1958. 23. Hooper, D. F.: ’Changing the Milieu in a Psychiatric Ward.’ Human Relations, 1962, 15:111-122. 24. Hurvitz, N.: ’Psychotherapy as a Means of Social Control.’ Journal of Consulting and Clinical Psychology, 1973, 40: 232-39. 25. Jones, M.: The Therapeutic Community. New York: Basic Books, Inc., 1953. 26. Kahne, M.: ’Bureaucratic Structure and Impersonal Experiences in Mental Hospitals.’ Psychiatry, 1959, 22:363-75. 27. Kumasaka, Y. and Stokes, J.: ’Involuntary Hospitalisation : Opinions and Attitudes of Psychiatrists and Lawyers.’ Comprehensive Psychiatry, 1972, 13: 201-08. 28. Kutner, M.: ’The Illusion of due Process in Commitment Proceedings.’ Northwestern Law Review, 1962, 57: 383-99. 29. Laing, R. D.: The Politics ofExperience. New York : Ballantine Books, 1967. 30. Lee, S. D. and Temerlin, M. K.: ’Social Class, Diagnosis, and Prognosis for Psycho-
therapy.’ Psychotherapy: Theory, Research and Practice, 1970, 7: 181-85. 31. Letemendia, F., Harris, A. D. and Willems, P. J. A.: ’The Clinical Effect on a Population of Chronic Schizophrenic Patients of Administrative Change in Hospital.’ Brit. J. Psychiat.,
1967, 113:959-71. 32.
Loeb,
M.: ’Role Definition in the Social World of
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In M. Green-
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33. 34. 35. 36.
37. 38. 39. 40. 41. 42. 43. 44. 45. 46.
et al. (eds.) The Patient and the Mental Hospital. Glencoe: The Free Press, 1957, pp. 14-19. P.: Treatment of Schizophrenia. New York: Science House, 1968. May, Mechanic, D.: ’Some Factors in Identifying and Defining Mental Illness.’ Mental Hygiene, 1962, 46 : 66-74. Medical World News, April 12, 1974. Mowrer, O. H.: ’Sin, the Lesser of Two Evils.’ Amer. Psychologist, 1960, 15:301-04. Oviatt, B. E.: ’Role Convergence in a Therapeutic Community.’ J. of the Fort Logan Mental Hospital Center, 1964, 2:117-29. Parloff, M. B.: ’The Impact of Ward-milieu Philosophies on Nursing-role Concepts.’ Psychiatry, 1960, 23 : 141-51. Parsons, T.: ’The Mental Hospital as a Type of Organisation.’ In M. Greenblatt et al. (eds.) The Patient and the Mental Hospital. Glencoe : The Free Press, 1957, pp. 108-29. Pearlin, L. I.: ’Alienation from Work.’ Amer. Sociolog. Review, 1962, 27 : 314-26. Phillips, D. L.: ’Rejection: A Possible Consequence of Seeking Help for Mental Disorders.’ American Sociological Review, 1963, 28: 963-72. Pine, F. and Levinson, D.: ’Two Patterns of Ideology Among Hospital Aides.’ In M. Greenblatt et al. (eds.) The Patient and the Mental Hospital. Glencoe : The Free Press.
1957, pp. 209-18. Rapoport, R. N.: Community as Doctor. Springfield : Chas. C. Thomas,1960. Rapoport, R. N, and Rapoport, R. S.: ’Permissiveness and Treatment in a Therapeutic Community.’ Psychiatry, 1959, 22:57-64. Rapoport, R. N. and Rapoport, R. S.: ’Democratisation and Authority in a Therapeutic Community.’ Behavioural Science, 1957, 2:128-33. Redl, F.: ’The Concept of a "Therapeutic Milieu" ’ Am. J. of Orthopsychiatry, 1959, 29 : 721-36.
47. Rosenhan, D. L.: ’On Being Sane in Insane Places.’ Science, 1973, 149:250-58. 48. Scheff, T.: ’Schizophrenia as Ideology.’ Schizophrenia Bulletin, 1970, 2 :15-19. 49. Scheff, T.: ’Social Conditions for Rationality: How Urban and Rural Courts Deal with the Mentally Ill.’ Amer. Behavioural Scientist, 1964, 7 : 21-27. 50. Scheff, T.: ’Control Over Policy by Attendants in a Mental Hospital.’ J. of Health and Human Behaviour, 1961, 2 : 93-105. 51. Schwartz, C. and Schwartz, M.: ’Social Processes in Mental Illness. New York : Columbia Press, 1962. 52. Schwartz, C.: ’Problems for Psychiatric Nurse Playing a New Role on a Mental Hospital Ward.’ In M. Greenblatt et al. (eds.) The Patient and the Mental Hospital. Glencoe : The Free Press, 1957, pp. 402-26. 53. Smith, H. and Levinson, D.: ’The Major Aims and Organisation Characteristics of Mental Hospitals.’ In M. Greenblatt et al. (eds.) The Patient and the Mental Hospital. Glencoe : The Free Press, 1957, pp. 3-8. 54. Stanton, A. and Schwartz, M.: The Mental Hospital. New York : Basic Books, Inc., 1954. 55. Star, S.: ’Public Attitudes—a Measure of Difficulties.’ In APA (ed.): Psychiatry, the Press and the Public. Washington, D.C., APA, 1956, pp. 1-12. 56. Stone, A.: ’Right to Treatment—Position of the APA Commission on Judical Action.’ Presented at the 128th Annual APA Meeting, Anaheim, Calif., May 5-9, 1975. 57. Stotland, E. and Kobler, A.: Life and Death of a Mental Hospital. Seattle: Univ. of Washington Press, 1965. 58. Szasz, T. S.: ’The Myth of Mental Illness.’ American Psychologist, 1960, 15: 113-18. 59. Thomas, A. and Sillen, J.: Racism and Psychiatry. New York : Brunner-Mazel, 1972. 60. Trachtman, J. P.: ’Socio-economic Class Bias in Rorschach Diagnosis: Contributing Psychosocial Attributes of the Clinician.’ J. Personality Assessment, 1971, 35: 229-40. 61. Wax, J.: ’Psychiatric Social Work.’ Amer. J. Psych., 1963, 119:659-61. 62. Wilensky, H. and Herz, M. I.: ’Problem Areas in the Development of a Therapeutic Community’. Intern. J. of Social. Psychiatry., 1966, 12: 299-308. 63. Wing, J. K. and Brown, G.: Institutionalism and Schizophrenia. London : Cambridge, 1970. 64. Wooden, H.: ’The System may Come Ahead of the Patient.’ The Modern Hospital, 1958, 91 : 99-104. 65. Zeitlyn, B. B.: ’The Therapeutic Community—Fact or Fantasy.’ Br. J. Psych., 1967, 113:1083-86.
Downloaded from isp.sagepub.com at DALHOUSIE UNIV on June 25, 2015
PROSPECTS FOR CHANGE IN PUBLIC MENTAL INSTITUTIONS CARL I. COHEN, M.D., M.A. Assistant Professor ofPsychiatry New York University-Bellevue Medical Center
Department ofPsychiatry Office ofUrban Health Affairs This paper is based on a manuscript that was awarded first prize in a essay contest sponsored by the New York District Branch of the A.P.A.; the paper was presented to this group on April 11, 1974. SUMMARY
Because of the incompatibility of variables (viz. actors, milieu concept, institution, society) with each other as well as the potential areas of strain contained within each variable, it is improbable that state mental institutions can adapt a patiencentered (therapeutic) milieu. Evidence is presented in order to substantiate this
hypothesis. social civil court and have for state institutions to rather than care. In order to this state institutions have emptied their wards. (35) Many psychiatric units have been reorganised along the lines suggested by Maxwell Jones (25) in an attempt to create a ’therapeutic community’ or ’patient-centered care’. Talcott Parsons (39) has ascribed to all mental hospitals four tasks : (a) custody of the deviant; (b) protection of the community; (c) socialisation of the deviant; (d) therapy. He observes that it is inevitable that these goals will conflict with one another. Furthermore, these tasks must be comprehended in the light of the conflicting needs of patients, staff, and the institution. (54) This paper proposes that it will be impossible to attain a ’true’ therapeutic milieu in state institutions because of the incompatibility of the variables (actors, milieu concept, institution, society) with each other. For example, the actors’ (staff and patient) roles may clash with the needs of the hospital or with the aims of the milieu community. Furthermore, each variable contains within itself areas of strain -actors have conflicting goals; the milieu concept is vague and of dubious value. A few of the conflicting relationships are delineated on page 264. various EGISLATORS, scientists, libertarians, psychiatrists, decisions underscored the necessity mental L provide therapy merely custodial (56) edict, comply with
I. The Actors A. The Patient-Definitional Problems At many public mental institutions patients are admitted against their will. For example, one-half of Bellevue’s admissions are on an involuntary basis. This
Address correspondence to : CARL I. COHEN, M.D., M.A. N.Y. U. Medical Center, Urban Health Affair 550 First Avenue, New York, 10016 Downloaded from isp.sagepub.com at DALHOUSIE UNIV on June 25, 2015
264
a clash between the patient and the doctor (and the community). Criteria for emergency admissions usually entail the notion of danger to self or others. Kumasaka and Stokes (27) have noted how lawyers and psychiatrists markedly differ on the concept of ’dangerousness’. ’Mental illness’ also is a rather nebulous concept and this lack of clarity regarding mental illness may pose a dilemma for the staff concerning the nature of what they are treating and it may put them at odds with the patient. The medical definition promulgated by the psychiatric profession has been undermined by other disciplines. Sociologists (15, 48, 34) have suggested that mental illness is a type ofI deviancy that is not readily classified under the more common deviant categories (e.g., theft, murder, etc.). Burger and Luckman (6) have pointed to psychiatry (along with technology, philosophy, and religion) as one of the legitimators of society. Laing (29) has asserted that schizophrenia is the logical escape from an insane environment (family or society). Mowrer (36) and Szasz (58) have proposed that mental illness represents a deviation from ethical norms, and they have provided cogent arguments debunking the physical basis of mental illness. Hurvitz (24) and Halleck (19) have described the political nature of psychotherapy-because most therapists focus on the intra-psychic sphere, they often obfuscate societal factors that may be impinging upon the patient. Socioeconomic factors similarly affect our conceptualisation of mental illness. Hollingshead and Redlich (22) have demonstrated the higher incidences of schizophrenia among lower socioeconomic groups. Lee and Temerlin (30) have suggested that knowledge of a patient’s social class biases the therapist’s diagnosis and prognosis assessment, i.e. lower economic groups are given more severe diagnosis. Several investigations of psychological tests (17,60) have uncovered racial and socioeconomic biases.
implies
I
I
Downloaded from isp.sagepub.com at DALHOUSIE UNIV on June 25, 2015
265 Because of public ignorance and fear of mental illness (41, 55) psychiatrists often pressured into making false-positive errors, believing it is better to error on -he side of caution. (49, 28) Hence, psychiatrists are often caught in the conflict between the patient and the community. are
~3. l.
The Staff Aides Staff needs and personalities often clash with the expectations of the milieu therapy. Studies have suggested that attendants’ personalities may be incompatible with a therapeutic community structure. To wit, Gilbert and Levinson (14) have noted that aides divide into two categories-’humanistically-oriented’ and ’custodialnriented.’ Pine and Levinson (42) believe that these two orientations are part of the aides total ideology and personality system; Appleby et al. (1) have demonstrated that new aides (less than six months experience) differed little in ideology and in opinions concerning mental illness than more experienced aides. Cohen and Struening (9) have reported that attendants scored high on authoritarianism, while psychologists, psychiatrists, and social workers scored low; nurses were midway between the two groups. The authors noted that if authoritarianism is characterologically imbedded as Adorno has suggested, no lecture series or brief course ill alter the aides’ attitudes. Pearlin (40) has pointed to the high degree of alienation among hospital orkers. Aides were the most vulnerable to alienation due to their low salaries and decreased opportunities for occupational advancement. As Herz (20) observed, therapeutic communities, while tending to blur roles, provide no mobility between oles, i.e. social workers do not become psychiatrists. Hence, milieu therapy may not significantly reduce alienation. Scheff (59) believes that the aides’ alienations and ow status may result in their sabotaging innovative efforts and maintaining the tatus quo. Wilensky and Herz (62) have confirmed this hypothesis by demonstrating hat lower-level personnel in a therapeutic community appeared to be reluctant to hare responsibilities and tend to guard jealously their assigned functions. Nurses. Nurses are overwhelmingly female [99%] and predominantly white [83-97%]. (10) The dominance of females in nursing may create problems with male physicians, hereas their whiteness may result in conflict with aides who are chiefly Black and uerto Rican (2) [see below]. Parloff (38) has demonstrated that for many nurses their previous training (e.g. emphasis on physical care) may be incompatible with ward-milieu philosophies nd despite long stay on the units, they are unable to adjust to many of the milieu
.
oncepts. .
Physicians Psychiatrists
are largely males [88%], (4) white [99%], (59) and in the highest socioeconomic class. (24) Band and Brody (2) have alluded to the potential conflicts hat can evolve between the physician and personnel in the lower socioeconomic lasses (nurses and aides); as well as the potential friction created by racial and difference. Physicians also find themselves enmeshed between various structural and educational commitments. In one hospital study, Stanton and Schwartz (54) reported hat therapists spent only 53% of their time with patients. In another hospital,
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266 Rosenhan
(47) noted that psychiatrists emerged on the ward an average of 6.7 times for rather brief periods. The remainder of a physician’s time may be divided into teaching duties, administrative work, and staff conferences. In state hospitals, administrative duties have traditionally been quite onerous. Cumming and Cumming (11) have indicated that psychiatrists frequently run into difficulty trying to resolve therapy versus administrative duties-often the physician yields to the old ways and the hospital culture rather than accepting significant administrative responsibility. Scheff (50) has pointed out that physicians have a ’trained incapacity’ for ward leadership based upon their previous training for individual psychotherapy. In addition to administrative overload, Belnap (3) has enumerated severa reasons for high physician turnover at state institutions : (a) low prestige; (b) pool working conditions; (c) higher salary elsewhere; (d) no opportunities for research (e) impossible to practice; (f) ill-defined and poor relations with superiors an professional auxiliaries. It would seem highly unlikely that the introduction into a state institution of a therapeutic milieu will result in a marked reduction in administrative overload o eliminate the etiology of physician turnover. per
day
II.
The Structure Smith and Levinson (53) believe that while the goal of the mental hospital is to assist the patient in the cure of his illness, the structure of the hospital organisation may hinder or help the effort. There are four basic problems created by the structure :
A.
Standardisation Versus Individuation Kahne (26) has illustrated how the bureaucratic nature of the institutio directly affects patient care-objective reporting becomes the standard for makin decisions; it is found in nursing reports, mental status examinations, and cas histories. For example, only disagreeable acts are reported, successes are rarely noted There is little evidence in the literature to suggest that recordkeeping has beer significantly modified in therapeutic milieus. Wooden (64) has warned that the difference between a hospital and a busines should be kept in mind; quite often the financial needs of an institution may com before patient care. B. Communication Difficulties in communication apparently are not eliminated by the therapeuti milieu. In the archetypical custodial care facility, Belnap (3) uncovered a shar dropoff in communication between Level II personnel (nurses, social workers occupational therapists), and Level III staff (aides). Etzioni (13) and Band et al. (2 have indicated that in the therapeutic milieu aides continue to remain circumspec about reporting communications upward out of fear that it will be used agains them. C. Status and Authority. It is difficult to imagine that patient-centered therapy will eliminate the statu rankings of participants. Etzioni (13) has asserted that the ward is not isolated fro the community, and cultural values are carried onto the ward. Band and Brody (2 have argued that racial, sexual, and socioeconomic status are potential arenas o conflicts among personnel and between staff and patient. Herz et al. (21) hav reported that attempts at role-blurring resulted in competition, hostility, conflic and anxiety among staff and patients. Oviatt (37) has similarly uncovered increase staff tensions engendered by overlapping of workers’ functions. ’
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267 Another method of status differentiation that may not be completely extinguished by the implementation of a therapeutic milieu is the ’diagnostic culture’. (32) In a mental hospital, the ability to employ psychiatric jargon often becomes a status
symbol. Relationship Between and Within Occupational Groups
D.
When there is too much functional differentiation of staff, it often becomes difficult to reach a concensus (26) or it may result in spotty care. (64) For these reasons, efforts to minimise occupational differences are often encouraged in therapeutic communities. Nevertheless, Etzioni (13) has contended that staff still maintain their affiliation with their professions through associations, journals, meetings, etc. Hence, many of the inter-disciplinary frictions continue to exist. III. Efficacy ofthe Therapeutic Milieu Another factor that may ultimately affect the prognosis of transformation to therapeutic wards in state institutions is whether milieu therapy is more efficacious than the custodial model. If there are repeated failures utilising milieu treatment, staff will become frustrated and they will revert to their previous roles. The data concerning its effectiveness are quite controversial. Clark (7) has described improvement in the behaviour of chronic patients subject to milieu therapy, but he is uncertain as to whether environmental conditions can alter the underlying psychosis. Letemendia et al. (31) studied a hospital ward run on the lines suggested by Maxwell Jones and after five years of study, long-stay patients experiencing a therapeutic milieu showed no differences when compared to a control group. Rapoport (43) has questioned whether techniques learned in the hospital are equally applicable in the community. Wing and Brown (63) have reported opposite findings they noted a diminishment in underlying pathology secondary to environmental alterations. Clark (7, 8) has pointed to the significant reductions in the length of hospitalisation that milieu therapy can produce when combined with drug and psychotherapy. However, as the sole treatment modality for Schizophrenia, milieu therapy has been shown to be the least effective of all therapies (versus drug, ECT, and psychotherapy). (33) Thus, our current exhortations to create ’therapeutic’ (patient-centered) institutions relies heavily on faith and on our personal beliefs on humanitarianism and and democracy rather than on objective data.
Why Organisations Do Not Change-The (Change’ Literature Merely altering the environment to a milieu regimen is not sufficient to guarantee therapeutic success; Hooper (23) discovered that despite apparent changes IV.
in the ward structure, there was still a minimum amount of interaction between the patient and the personnel. The literature is replete with references concerning staff resistance to change. (50, 11, 3) Dykins et al. (12) have noted that a hospital culture frequently operates on a variety of premises such as ’others are not interested in change’ or that ’these things have been tried before’. Nevertheless, despite these responses by staff members, the hospital under study had historically accepted new treatment techniques. Therefore, staff resistance to change may not be such a potent element, several authors (16, 5) have posited other items that may play a more significant role in impeding innovations :
A.
Lack of clarity regarding the innovations Schwartz’s (52) observations in one hospital in which
nurses
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failed
to
adapt
to
268
therapeutic milieu have suggested that this failure lies with the administrator who has a responsibility to interpret the role to them, and to help them play the new role. One of the major difficulties with a therapeutic community is lack of clarity regarding what is expected from the staff. Part of the problem lies in the inability to arrive at a concensus regarding a definition of ’therapeutic milieu’; (65) Fritz Redl (46) has drolly commented that there are at least seven commonly used
a
definitions.
I
Rapoport (43, 45, 46) has amply demonstrated the confusion among staff regarding when to act ’permissively’ or when to be ’democratic.’ Wilensky and Herz (62) believe that the inappropriately paternalistic attitude that staff exhibited towards patients on one therapeutic ward stemmed from a poor understanding of the theoretical bases for staff-patient relationships. B. Lack of needed capabilities Hall (18) has maintained that the new milieu approach has not given sufficient attention to the education of nurses and aides. Except for a brief educational session, the aides are totally unprepared to function adequately in a treatment milieu. If one compares the education of a psychiatric resident (medical school, seminars, supervision, personal analysis) with that of an aide, one can see the ludicrousness in the aide’s situation. Furthermore, one must consider data presented by Cohen & Struening (9) alluding to the possible incompatibility of the aide’s personality structure with milieu therapy. C. Incompatibility of organisational arrangements with the innovation Schwartz and Schwartz (51) have summarised three organisational items that may impede change : (a) large ward size and low staff-patient ratios; (b) conflicting goals (custodial versus treatment); that is, despite some enhanced permissiveness there is still a necessity to maintain order; (c) forced standardisation due to overall hospital policy, government regulations, etc. Rapoport (45) has also delineated several factors external to the hospital that may conflict with ward policies. For example, a limitation on sexual freedom on the ward may result because of societal pressure. T,a ck of staff motivation Schwartz (52) has asserted that new roles must offer various rewards, and that attPntion should be directed to the gratifications being provided. She exhorts administrators to constantly search for ways to increase motivation and to decrease apathv : attempts should be made to fit the new role into the more traditional roles and value systems. Stotland and Kobler (57) believe that high staff morale is essential for the survival of a therapeutic milieu approach. They contend that if morale markedly diminishes the organisation will ultimately die.
D.
SUMMARY
Because of the incompatibility of variables (actors, milieu concept, institution, society) with each other as well as the potential areas of strain contained within each variable, it is improbable that state mental institutions can adapt a patientcentered (therapeutic milieu). Evidence is presented in order to substantiate this
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